Inpatient Coding Using MDM Table
Inpatient coding involves assessing the complexity of patient care through the Medical Decision
Making (MDM) table, which is structured into three components:
1. Number and Complexity of Problems Addressed
2. Amount and/or Complexity of Data to be Reviewed and Analyzed
3. Risk of Complications and/or Morbidity or Mortality of Patient Management
For inpatient coding, the MDM table helps determine the level of service provided during the hospital
stay. Below, we discuss each component with inpatient-focused examples:
1. Number and Complexity of Problems Addressed:
- Straightforward: Patient admitted for observation of a minor condition, such as dehydration
without complications.
- Low Complexity: Patient admitted with stable hypertension managed with existing medications.
- Moderate Complexity: A patient admitted with pneumonia requiring IV antibiotics and monitoring
for respiratory distress.
- High Complexity: Patient with multiple organ failure, requiring intensive monitoring and
management of complex conditions.
Example: A patient with acute kidney injury, congestive heart failure, and diabetes admitted for
management. The provider addresses multiple chronic conditions with exacerbations, aligning with
high complexity.
2. Amount and/or Complexity of Data to be Reviewed and Analyzed:
- Straightforward: Reviewing a single lab test result.
- Low Complexity: Reviewing a single diagnostic imaging report and basic lab tests.
- Moderate Complexity: Independent interpretation of imaging and obtaining history from multiple
sources.
- High Complexity: Coordination of care with multiple specialists, review of complex imaging, and
analysis of multiple diagnostic tests.
Example: A patient admitted with chest pain undergoes cardiac catheterization, echocardiogram,
and continuous cardiac monitoring. The physician also discusses test findings with a cardiologist.
This scenario involves high data complexity.
3. Risk of Complications and/or Morbidity or Mortality of Patient Management:
- Straightforward: Routine follow-up with no risk factors.
- Low Risk: Minor procedures or initiation of oral medications.
- Moderate Risk: New medication with potential side effects or minor surgery with risk factors.
- High Risk: Intensive monitoring of a patient in sepsis requiring multiple interventions and
potential surgical intervention.
Example: A patient with diabetic ketoacidosis (DKA) requiring continuous insulin infusion and
electrolyte management is considered high risk due to the potential for life-threatening
complications.
Utilizing MDM Table in Inpatient Coding:
- Documentation Requirements: Detailed and accurate documentation is essential to justify the
MDM level selected. Include comprehensive notes regarding the number of problems addressed,
data reviewed, and risk factors.
- MDM Level Selection: The overall MDM level is determined by meeting or exceeding two of the
three components.
- Compliance: Ensure that each documented component aligns with the selected level to avoid
denials or downcoding.
By applying the MDM table effectively, inpatient coders can accurately reflect the complexity of care
provided and ensure appropriate reimbursement for services rendered.